Number of adverse health events up in 2018

The number of reportable adverse events in Minnesota hospitals, ambulatory surgical centers and community behavioral health hospitals has been slowly increasing for the last five years, and these events reached their highest number, 384 events out of 5 million patient days, between October 2017 and October 2018.

The annual adverse health events report is part of Minnesota's strong public-private partnership dedicated to quality improvement. Though the number of events increased again in 2018, these events remained very rare and their very low frequency – far below 1 percent of hospitalizations – has remained steady over the past 15 years of reporting.

Minnesota's Adverse Health Events reporting system tracks 29 serious events, such as wrong-site surgeries, severe pressure ulcers, falls and serious medication errors, which should rarely or never happen. Before this first-in-the-nation system was launched, there was no statewide system for assessing how frequently errors such as these, which are usually preventable, happened in hospitals or ambulatory surgical centers.

"This system has given us a much deeper understanding of how and why adverse events occur, and it has helped create a culture of learning and improvement across Minnesota. But despite earnest collaboration and effort, in the last few years of reporting, the number of reported events has plateaued in several categories and increased in others," said Minnesota Health Commissioner Jan Malcolm. "It is clear there is still more to do to keep patients safe every time they receive care. We look forward to working with our partners this year to ensure this system can continue to improve, evolve and get results."

Of the reports submitted during this reporting period, 31 percent resulted in serious injury (118 events), while 11 (2 percent) led to the death of a patient, according to the Adverse Health Events in Minnesota 15th Annual Public Report.

Falls, severe pressure ulcers, medication errors and product/device malfunction have been the most common causes of serious patient injury or death. The pattern was similar in 2018. Five of the 11 deaths were associated with falls, three with the death of a neonate, two with medication errors and one as the result of a suicide.

"Every one of the numbers in the adverse health events report represents a patient, family and health care team," said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association. "This statewide reporting and learning system enables us to analyze every adverse event and spread lessons learned across the state. Our transparent learning approach ensures that future adverse events can be prevented though a continuous proactive effort across the state, every day of the year."

The increase in events noted in this reporting period was largely driven by a rise in pressure ulcers, retained foreign objects and the loss or damage of irreplaceable biological specimens.

In 2018, hospitals and surgical centers reported 33 cases of retained foreign objects. While the ten-year trend shows a decrease, the number of events has increased over each of the last four years, which signals an opportunity for improvement.

Hospitals and surgical centers had an intense focus on preventing wrong-site procedures in 2018 and reduced these events by one-third.

The number of reported pressure ulcers increased in 2018, from 120 to 147. Pressure ulcers have generally been on an upward trend for the past six years.

As part of the reporting system, MDH, the Minnesota Hospital Association (MHA) and Stratis Health implemented a number of actions in 2018 including new medication reconciliation practices for reducing medication errors, a device-related pressure injury prevention toolkit, significant focus on wrong-site procedures and training related to improving root-cause analysis and preventing suicide and self-harm.